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VIRGINIA DEPARTMENT ENTITLEMENT TO RESTORATION OF SOCIAL SERVICES OF LOST BENEFITS

10/24 VOLUME V, PART XXIV, PAGE 61

ENTITLEMENT TO RESTORATION OF LOST BENEFITS

FORM NUMBER - 032-03-0153

PURPOSE OF FORM - To notify a household of its entitlement to restoration of lost benefits.

USE OF FORM - To be completed at the time the local agency determines a household is entitled to restoration of lost benefits, or denies a request for restoration.

NUMBER OF COPIES - Two.

DISPOSITION OF FORM – Send a copy to the household and retain a copy in the case record.

INSTRUCTIONS FOR PREPARATION OF FORM

Complete the identifying information at the top.

Check the first box to inform a household that it is entitled to a restoration. Complete the information requested on the form. If the restoration was offset against an amount which was previously overissued, check the small block in the second paragraph and complete the information requested.

Check the second box if the request for restoration is denied and complete the information requested.

Complete the information at the bottom of the form.

TRANSMITTAL #35